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PHRM 865 > Exam 3: Skin and Soft Tissue/Bone and Joint/Endocarditis > Flashcards

Exam 3: Skin and Soft Tissue/Bone and Joint/Endocarditis Flashcards

1
Q

What are most skin and soft tissue infections caused by

A

beta hemolytic strep and/or staph aureus

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2
Q

Mechanisms of defense against SSTIs

A
  1. Skin as physical barrier
  2. Continuous renew of epidermal layer
  3. Low pH
  4. Dry
  5. Normal bacterial flora that inhibit growth of pathogenic bacteria and compete for nutrients
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3
Q

Contents of normal skin flora

A
  1. beta hemolytic strep

2. coagulase negative staph

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4
Q

what is impetigo

A

superficial skin infection involving the epidermis consisting of multiple, coalescing erythematous papules that evolve into pustules or vesicles that rupture and form a dried, honey-colored crust/dischard on an erythematous base

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5
Q

impetigo symptoms

A

maculpapular lesions that rupture leaving superficial erosions that are occasionally prutic or painful with honey-colored-crust –> non-bolus

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6
Q

impetigo pathogenesis

A

organism can directly invade healthy skin (primary) or can be introduced into superficial layers of the skin (epidermis) during trauma or abrasion (secondary); non-bullous form is highly contagious

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7
Q

main at risk group for impetigo

A

children

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8
Q

impetigo bacteriology

A

staph aureus and/or strep pyogenes (group a strep)

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9
Q

impetigo mild treatment

A

topical:

mupirocin 2% or retapamulin 1% bid x5

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10
Q

when to give systemic treatment for impetigo

A

patients with numerous lesions or during outbreaks affecting several people to help decreased transmission

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11
Q

length of systemic impetigo treatment

A

7 days

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12
Q

impetigo antibiotics

A 
docloxacillin
cephalexin
erythromycin
clindamycin
augmentin
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13
Q

dicloxacillin impetigo dosing

A

500 mg q 6

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14
Q

cephalexin impetigo dosing

A

500 mg q 6

25-30 mg/kg/day in 3-4 doses

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15
Q

erythromycin impetigo dosing

A

500 mg q 6

40 mg/kg/day in 3-4 doses

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16
Q

clindamycin impetigo dosing

A

300 mg q 8

20mg/kg/day in 3 doses

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17
Q

augmentin impetigo dosing

A

875mg q 12

25 mg/kg/day bid

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18
Q

what is cellulitis

A

acute, diffuse, spreading infection involving the skin and subcutaneous tissue, with or without fascial involvement

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19
Q

cellulitis symptoms

A

rapidly spreading area of redness, tenderness, warmth, and swelling in the skin with a poorly defined border

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20
Q

cellulitis pathogenesis

A

organism is introduced into the skin during trauma, wounds, athlete’s feet, dry/cracked skin, injection drug use, ulcers, or surgery

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21
Q

how many extremities does cellulitis cover

A

usually on one

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22
Q

what is erysipelas

A

variant of cellulitis caused by beta hemolytic strep involving only the upper dermis and superficial lymphatics with intense erythema and clearly defined borders

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23
Q

erysipelas characteristics

A

peau d’orange (orange peel) appearance due to superficial cutaneous edema surrounding the hair follicles
most often involves the FACE

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24
Q

common causative organisms of MRSA

A

s. pyogenes

s. aureus

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25
Q

CA-MRSA characteristic

A

cellulitis AND abscess

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26
Q

when should CA-MRSA be suspected

A

in any patient with a skin and soft tissue infection that includes an abscess or drainable focus of infection, or not responding to beta lactams

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27
Q

cellulitis diagnostic factorssh

A

redness, pain, warmth
poorly defined border
increased WBC

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28
Q

cellulitis empiric therapy recommendation

A

empiric therapy should be directed against BOTH staph aureus and group A strep

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29
Q

adult treatment mild /moderate cellulitis

A

dicloxacillin 250-500 q 6 h
or
cephalexin 500 q 6 h

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30
Q

adult treatment mild /moderate cellulitis if MRSA suscpected

A 
bactrim 2bid 
or
clindaycin 300-450 QID
or 
Linezolid 600 BID
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31
Q

pediatric treatment mild /moderate cellulitis

A

dicloxacillin 25-50mg/kg/day QID
or
cephalexin 25-50 mg/kg/day QID

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32
Q

pediatric treatment mild /moderate cellulitis if MRSA suspected

A 
Bactrim 8-12 mg/kg/day BID
or
Clindamycin 8-20 mg/kg/day TID
or 
Linezolid 10mg/kg BID
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33
Q

adult treatment moderate to severe cellulitis

A

Nafcillin 1-2g q 4-6
or
Cefazolin 1-2g q 8

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34
Q

adult treatment moderate to severe cellulitis if mrsa suspected

A

vanc 10-15mg/kg q 12
or
linezolid 600 q 12

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35
Q

pediatric treatment moderate to severe cellulitis

A

nafcillin 150-200 mg/kg/day q 4-6 (max 12g/day)
or
cefazolin 50-100mg/kg/day TID

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36
Q

pediatric treatment moderate to severe cellulitis if mrsa suspected

A

vanc 10-15 mg/kg q 12

or linezolid 10 mg/lg q 12

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37
Q

what is CA-MRSA resistant to

A

beta lactams

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38
Q

treatment duration for cellulitis

A

5 days

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39
Q

what is necrotizing fasciitis

A

rare, agressive skin/sq infection that also involves the fascia characterized by progressive destruction of fascia, sq fat, and muscle

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40
Q

necrotizing fasciitis symptoms

A

symptoms of cellulitis and intense pain, bullae, crepitus, wooden-hard induration, cutaneous gangrene and systemic toxicity

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41
Q

necrotizing fasciitis pathogenesis

A

same as cellulitis but caused by toxin producing organism(s) that progressively destroys superficial fascia and sq fat

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42
Q

necrotizing fasciitis diagnosis

A

Wooden hard induration, pain out of proportion to PE
elevated WBC
culture of deep tissue obtained during surgery
blood cultures
CT or MRI document fascial edema

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43
Q

primary treatment of necrotizing fasciitis

A

surgical intervention and repeat surgical debridement and drainage 1 24-36 hours until infected/necrotic material is no longer present

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44
Q

necrotizing fasciitis antibiotic therapy

A

vanc
pip/tazo or meopenem
clindamycin

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45
Q

what is preferred antibiotic therapy for necrotizing fasciitis and why

A

clindamycin –> suppresses toxin and cytokine production of strep

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46
Q

length of antibiotic therapy for necrotizing fasciitis

A

Therapy should be administered until further surgical
debridement is no longer necessary, the patient has shown
clinical improvement, and fever has been absent for 48-72
hours.

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47
Q

DFI pathogenesis

A

caused by the presence of neuropathy, angiopathy with ischemia, dry skin, decreased wound healing, and immune defectes associated with DM

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48
Q

are all diabetic foot wounds infected?

A

No

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49
Q

what classifies a DFI

A

At least 2 of:

erythema, warmth, swelling/induration, tenderness, pain, purulent discharge, systemic signs

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50
Q

mild DFI wound classification

A

< 2cm cellulitis around wound
infection only in skin/superficial tissue
patient WITHOUT SIRS

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51
Q

moderate DFI wound classification

A

cellutlitis extends >2 cm or involves structures deeper than skin/sq tissue
patient WITHOUT SIRS

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52
Q

severe DFI wound classification

A

local infection with signs of SIRS

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53
Q

DFI diagnosis

A

S/s and wound classificatin
Increased WBC, ESR, CRP
Radiography for osteo

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54
Q

overall treatment approach to treat DFI

A

comprehensive approach –> optimal wound care (debridement, whirlpool, dressing changes), glucose control, restriction of activities (bed rest), antibiotics

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55
Q

Mild DFI empiric therapy non MRSA

A

PO cephalexin
PO dicloxacillin
PO augmentin

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56
Q

Mild DFI empiric therapy MRSA suspected

A

PO Clindamycin

PO bactrim

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57
Q

Moderate DFI empiric therapy

A

IV cefazolin

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58
Q

Moderate DFI enterobacteriacae empiric therapy

A

IV ceftriaxone

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59
Q

Moderate DFI obligate anaerobes empiric therapy

A

PO metronidazole

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60
Q

Severe DFI empiric therapy

A 
Vanc PLUS
pip/tazo or
meropenem or
ceftazidime/cefepime with PO metronidazole or
levo/cipro with metronidazole
61
Q

duration of therapy mild DFI

A

1 to 2 weeks, may extend up to 4 weeks if slow to resolve

62
Q

duration of therapy moderate DFI

A

1 to 3 weeks

63
Q

duration of therapy severe DFI

A

2 to 4 weeks

64
Q

what side of the heart is the tricuspid valve at

A

right

65
Q

what side of the heart is the mitral valve at

A

left

66
Q

what is IE

A

syndrome resulting in colonization or invasion of the endocardium by various types of microorganisms

67
Q

etiologic agents in IE

A

staph (30-70%) s. aureus

strep (10-28%) viridans

68
Q

valvular endothelium pathophysiology IE

A

valvular endothelium undergoes trauma causing platelet-fibrin deposition, which allows for adherence and colonization

69
Q

bacterial growth in IE

A

bacterial growth in vegetation in unimpeded due to lack of host defenses

70
Q

valvular tissue in IE

A

may lead to acute heart failure via perforation of valve leaflet or rupture of the chordae tendinae or papillary muscle

71
Q

cardinal symptom in IE

A

heart murmur

72
Q

important laboratory test in IE

A

blood cultures –> bacteremia is continuous and low grade

73
Q

how long does it take for complete eradication in IE

A

weeks

min 2 weeks, but can be up to 4-6 weeks

74
Q

surgical intervention IE requirement

A
  • persistent vegetation after systemic embolization
  • anterior mitral valve leaflet vegetation >10mm
  • > 1 embolic event during first two weeks of antimicrobial therapy
  • increased vegetation size despite appropriate antimicrobial therapy
  • valve rupture
  • caused by resistant organisms
  • abscess
75
Q

Highly penicillin susceptible Virdians Group Strep and S. gallolyticus: NVE treatment preferred in patients >65 years or with renal or hearing dysfunction

A
  • pen G for 4 weeks or

- ceftriaxone for 4 weeks

76
Q

Highly penicillin susceptible Virdians Group Strep and S. gallolyticus: NVE treatment not intended for patient with known cardiac or extracardiac abscesses or ClCr <20
Peak of 3-4; trough <1

A

-pen g for 2 weeks +

gentamicin for 2 weeks

77
Q

Highly penicillin susceptible Virdians Group Strep and S. gallolyticus: NVE treatment Peak of 3-4; trough <1

A

ceftriaxone for 2 weeks + gentamicin for 2 weeks

78
Q

Highly penicillin susceptible Virdians Group Strep and S. gallolyticus: NVE treatment only for patients unable to tolerate beta lactams; target trough 10-15

A

vanc for 4 weeks

79
Q

penicillin relatively resistant Virdians Group Strep and S. gallolyticus: NVE treatment

A

pen g OR ceftriaxone for 4 weeks PLUS

gentamicin for 2 weeks

80
Q

penicillin susceptible Virdians Group Strep and S. gallolyticus: PVE treatment

A

Pen G OR ceftriaxone for 6 weeks WITH OR WITHOUT gentamicin for 2 weeks

81
Q

penicillin relatively resistant Virdians Group Strep and S. gallolyticus: PVE treatment

A

Pen G OR ceftriaxone for 6 weeks PLUS gentamicin for 6 weeks

82
Q

Staph NVE oxacillin susceptible strains treatment

A

nafcillin or oxacillin for 6 weeks

83
Q

Staph NVE oxacillin susceptible strains treatment for pen-allergic non anaphylaxis

A

cefazolin for 6 weeks

84
Q

Staph NVE oxacillin resistant strains treatment

A

vanc for 6 weeks

85
Q

Staph NVE oxacillin resistant strains treatment right sided IE only

A

daptomycin

86
Q

Staph PVE oxacillin susceptible strains treatment

A 
nafcillin or oxacillin x 6 wk
PLUS
rifampin x 6 wk 
PLUS 
gentamicin x 2 wk
87
Q

Staph PVE oxacillin resistant strains treatment

A 
gentamicin x 6 wk
PLUS
rifampin x 6 wk 
PLUS 
vanc x 2 wk
88
Q

Enterococci- N/PVE treatment penicllin/gentamicin suscpeptible; able to tolerate beta lactam therapy

A

ampicillin x 4-6 wk
PLUS
gentamicin x 4-6 wk

89
Q

Enterococci- N/PVE treatment penicllin/gentamicin suscpeptible; able to tolerate beta lactam therapy when ClCr > 50

A

penicillin x 4-6 wk
PLUS
gentamicin x 4-6 wk

90
Q

Enterococci- N/PVE treatment penicllin/gentamicin suscpeptible; able to tolerate beta lactam therapy when ClCr <50

A

ampicillin x 6 wk

ceftriaxine x 6 wk

91
Q

Enterococci- N/PVE treatment penicllin suscpeptible/ AG resistant normal renal functin

A

ampicillin x 6 wk
PLUS
ceftriaxone x 6 wk

92
Q

Enterococci- N/PVE treatment penicllin suscpeptible/ AG resistant/ strep susceptible

A

Ampicillin x 4-6 wk
PLUS
streptomycin x 4-6 wk

93
Q

Enterococci- N/PVE treatment unable to tolerate beta lactam therapy; vanc and AG susceptible strains

A

vanc x 6 wk
PLUS
gentamicin x 6 wk

94
Q

Enterococci- N/PVE treatment intrinsic resistance to penicllin or beta lactamase producer

A

vanc x 6 wk
PLUS
gentamicin x 6 wk

95
Q

Enterococci- N/PVE treatment penicillin/AG/vanc resistant strains

A

daptomycin >6 wk

linezolid > 6 week

96
Q

HACEK organisms N/PVE preferred therapy

A

ceftriaxone x 4-6 wk

97
Q

most common cause of osteomyelitis

A

staph aureus

98
Q

standard duration of treatment for acute osteomyelitis

A

4 to 6 weeks

99
Q

what is osteomyelitis

A

purulent inflammation of the bone marrow and surrounding bone associated with an infection

100
Q

osteomyelitis hematogenous spread

A

pathogen reaches bone via bloodstream

101
Q

osteomyelitis contiguous spead

A

pathogen reaches the bone from an adjacent soft tissue infection or direct inoculation during trauma, puncture wounds, surgery

102
Q

osteomyelitis vascular insufficiency

A

subset of contiguous spread: infection develops as an extension of existing localized infection

103
Q

best way to diagnose osteomyelitis

A

Culture of infection bone an blood and MRI

104
Q

treatment needed for osteomyelitis

A

combo of medical and surgical

105
Q

newborn osteomyelitis empiric treatment

A

nafcillin or oxacilli
+
cefotaxime

106
Q

children < 5 osteomyelitis empiric treatment vaccinated

A

nafcillin or cefazolin

107
Q

children < 5 osteomyelitis empiric treatment not vaccinated

A

cefotaxime

108
Q

children >5 osteomyelitis empiric treatment

A

nafcillin

cefazolin

109
Q

adults osteomyelitis empiric treatment

A

nafcillin

cefazolin

110
Q

injection drug users osteomyelitis empiric treatment

A

pip/tazo
cefepime
meropenem

111
Q

post-op osteomyelitis empiric treatment

A

pip/tazo
cefepime
meropenem

112
Q

vascular insufficiency osteomyeltis empiric treatment

A

pip/tazo
meropenem
beta lactcam or FQ + metronidazole

113
Q

s. aureus osteomyelitis empiric treatment

A

naficillin

cefazolin

114
Q

strep pen susc osteomyelitis empiric treatment

A

aqueous pen G

ceftiaxone

115
Q

enteroocci or streptococci osteomyelitis empiric treatment

A

aqueous pen G

ampicillin

116
Q

gram negative bacilli osteomyelitis empiric treatment

A

ceftriaxone
cefepime
cipro

117
Q

p. aeruginosa osteomyelitis empiric treatment

A

cefepime
pip/tazo
cipro

118
Q

polymicrobial osteomyelitis empiric treatment

A

meropenem
ertapenem
pip/tazo

119
Q

what is septic arthritis

A

inflammatory reaction within the synovial membrane, synovial fluid, articular cartilage and joint space caused by presence of a microorganism

120
Q

bacterial septic arthritis urgency

A

rheumatologic emergency due to potential for rapid joint destruction and irreversible loss of function

121
Q

septic arthritis is primarily caused by what

A

s. aureus

122
Q

septic arthritis clinical presentation

A

monoarticular

123
Q

septic arthritis classic triad

A

dermatitis, tenosynovitis, polyarthralgia

124
Q

gram postive cocci septic arthritis empiric therapy

A

vanc

125
Q

gnc septic arthritis empiric therapy

A

ceftriaxone

126
Q

gnb septic arthritis empiric therapy

A

cefepime
pip/tazo
meropenem

127
Q

gnb septic arthritis empiric therapy if severe allergy

A

aztreonam
cipro
levo

128
Q

gsn septic arthritis empiric therapy

A

vanc +
ceftriaxone or cefepime OR
FQ OR
AG

129
Q

septic arthritis s. aureus, gram negative duration of treatment

A

4 weeks

130
Q

septic arthritis streptococci duration of treatment

A

min 2 weeks

131
Q

septic arthritis gonococci duration of treatment

A

7-10 days

132
Q

what is a PJI

A

infection occurring in prosthetic joint with the presence of a sinus tract that communicates with the prosthesis

133
Q

do you use surgery as a treatment option for PJI

A

yes

134
Q

preferred PJI treatment MSSA

A

nafcillin
cefazolin
ceftriaxone

135
Q

alternative PJI treatment MSSA

A

vanc
dapto
linezolid

136
Q

preferred PJI treatment MRSA

A

vanc

137
Q

alternative PJI treatment MRSA

A

dapto

linezolid

138
Q

preferred PJI treatment pen-s enterococcus

A

penicillin

ampicillin

139
Q

alternative PJI treatment pen-s enterococcus

A

vanc
dapto
linezolid

140
Q

preferred PJI treatment pen-r enterococcus

A

vanc

141
Q

alternative PJI treatment pen-r enterococcus

A

dapto

linezolid

142
Q

preferred PJI treatment p. aeruginosa

A

cefepime

meropenem

143
Q

alternative PJI treatment p. aeruginosa

A

cipro

ceftazidime

144
Q

preferred PJI treatment enterbacter

A

cefepime

ertapenem

145
Q

alternative PJI treatment enterbacter

A

cipro

146
Q

preferred PJI treatment enterobacteriaceae

A

IV beta lactam

cipro

147
Q

preferred PJI treatment beta hemolytic strep

A

penicillin

ceftriaxone

148
Q

alternative PJI treatment beta hemolytic strep

A

vanc

PHRM 865 (59 decks)

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